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NEWBORN

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Hilary Soderborg

on 12 March 2015

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Transcript of NEWBORN

NEWBORN
TEETH
Most newborns do not have teeth.

Natal teeth are teeth present at birth that normally on the lower gum, attached with soft tissue and without a strong root.

Neonatal teeth are teeth that emerge through the gingiva during the first
month of life.

Removed based on if they are causing difficulty to the infant or mother.

PSYCHOSOCIAL

Basic needs are met by the parents or caregiver and this interaction leads to trust or mistrust.

Warmth, regularity, and dependable affection will lead to trust.

Lack of basic needs and affection, inconsistency, neglect, or abuse will lead to mistrust.

IMMUNIZATIONS
Hepatitis B Vaccine

Hep B negative mothers- administer before discharge

Hep B positive mothers-administer vaccine and HepB immune globulin within 12 hours after birth

Dosage- 0.5ml IM in the vastus lateralis muscle

Administered at birth, 1 to 2 months, and 6 to 18 months of age.

FINE AND GROSS MOTOR DEVELOPMENT
SABRINA | MEREDYTH | KATE LYNN

MACY | KATIE | HILARY | CANDACE

ASSESSMENT
HEAD

• Head Circumference
o Measure occipitofrontal circumference
o Normal 32-36.8 cm

• Fontanels
o Palpate, inspect, and note size and status (open or closed)
o Anterior fontanel 5-cm diamond increasing as molding resolves; Posterior fontanel triangle, smaller than anterior

• Sutures
o Palpable and separated sutures with possible overlapping

SKIN
MOUTH
o Symmetry of lip movement or
transient circumoral cyanosis

o Pink gums

o Tongue not protruding, freely movable,
symmetric in shape and movement

o Soft and hard palates intact;
uvula midline

o Distinct chin; mouth should
be moist and pink

o Check reflexes:
rooting and sucking

CHEST
• Almost circular, barrel shape

• Rib cage symmetric and intact

• Nipples should be prominent, well formed; symmetrically placed

• Evaluate clavicles to make sure they are intact

LUNGS
• Breath Sounds
o Bronchial; loud and clear
o Crackles may be heard after birth

• Respiratory Effort
o Tendency to be shallow and irregular in rate, rhythm, and depth when infant is awake

• Color
o Generally pink
o Mottling, Harlequin sign, plethora, telangiectases, milia, and petechiae over presenting part are normal

• Texture
o Slightly thick; superficial cracking,
peeling, especially of hands and feet is normal

• Other
o Observe for jaundice
o Observe for birthmarks
(Mongolian spots are normal)
o Gently pinch skin to assess turgor
and check hydration status
o Check for vernix caseosa
o Assess lanugo
HEARING
• Similar to adult once
amniotic fluid drains

• Respond to low-frequency sounds such as a heartbeat or lullaby

• Prefers to hear human voice
esp. mother

• A routine hearing screening is recommended for all newborns before discharge

HEART
• Rhythm
o Should be regular with 120 to 160 bpm but it is common to detect brief irregularities

• Murmur
o Can be a normal variation, especially over base or at left sternal border
in interspace 3 or 4

• Pulses
o Peripheral pulses equal
bilaterally and strong

EARS
o Correct placement line drawn through
inner and outer canthi of eyes reaching
to top notch of ears

o Well formed, firm cartilage
o Perform hearing screening

CRY

o Used to assess initial respiratory effort and reflexes

o Should be a good, loud cry

NOSE
o Should be midline with some mucus but no drainage; preferential nose breather; sneezing to clear the nose

(a slight deformity is normal)
EYES
o Check placement on face: eyes and space between eyes each 1/3 the distance from outer-to-outer canthus

o Check for symmetry in size/shape; check for eyelids size, movement and blinking

o Check pupils; assess for discharge (infection)

NEWBORN PHYSICAL ASSESSMENT
ABDOMEN
• Umbilical cord should have 2 arteries
and 1 vein and should appear a whitish gray
• Some babies may have what is called a
reductible umbilical hernia
• Overall it should be rounded, have no
distention or palpable masses
• Separation of the abdominal muscles can sometimes be present
• Bowel sounds should be present
minutes after birth
• Linea nigra could be present
GENITALIA
o Clitoris should be edematous

o Labia major is edematous and covers the labia minora; vernix caseosa sometimes present

o May be smegma discharge (collection of dead skin cells and body oils), can also be blood tinged

o Vagina should be open and have mucoid discharge

o Should void 2-6 times per day for
first 2 days, by day 4, they should be
going 6-10 times a day

EXTREMITIES
• Newborn should appear to be in
same position it was in utero
• Should have full ROM and move spontaneously
• Arms should be longer than legs
• Acrocyanosis is a common finding
• Check for 10 fingers and 10 toes
• Femur should be intact
• Gluteal folds should be even
• Bottoms of the feet should have wrinkles
• All extremity joints should have full ROM

BACK
• Spine should be straight and easily flexed
• Shoulders, scapulae and iliac crests should all be in line
• Look for pilonidal dimple or sinus

FEMALE
GENITALIA
MALE
o Foreskin should cover the glans with the meatus
at the tip of the penis; should not be retractable

o Scrotum should have visible wrinkles called
rugae; is large and edematous

o Testes should be palpable on both sides

o Cremasteric reflex should be present
which retracts the testes

BASIC TRUST vs MISTRUST
SLEEP-WAKE
STATES
 Healthy newborns differ in their activity levels, feeding patterns, sleeping patterns and responsiveness.

 Infants tend to alternate periods of sleep and wakefulness that resemble their fetal inactivity and activity patterns

 Variations in the state of consciousness of infants are called
sleep-wake states

 The six states form a continuum from deep sleep to extreme irritability

 Two sleep states:
 Deep sleep
 Light sleep

 Four wake states:
 Drowsy
 Quiet alert
 Active alert
 Crying

 Each state has specific
characteristics and state-related behaviors

 The optimal state of arousal is the

quiet alert state.

 During this state infants smile, vocalize, move in synchrony with speech, watch their parents’ faces, and respond to people talking to them

 The ability to regulate sleep-wake states is called
state modulation
.

 The ability to regulate sleep-wake states is essential in the infant’s neurobehavioral development.

Infants use the purposeful behaviors to
maintain the optimal arousal state as follows:

1. Actively withdrawing by
increasing physical distance
2. Rejecting by pushing away
with hands and feet
3. Decreasing sensitivity by falling asleep or
breaking eye contact by turning head
4. Using signaling behaviors such as
fussing and crying

 These behaviors permit infants to quiet
themselves and reinstate
readiness to interact.

WHAT TO EXPECT AS A PARENT
 For the first few weeks the wakeful periods seem dictated by hunger, but soon a need for socializing appears

 The newborn sleeps on average approximately 17 hours a day, with periods of wakefulness gradually increasing

 By the fourth week of life some infants stay awake from one feeding to the next.

SLEEP
TOUCH
 The infant is responsive to touch on all parts of the body.
 Reflexes can be elicited by stroking the infant
 The newborn’s responses to touch suggest that this sensory system is well prepared to receive and process tactile messages
 Touch and motion are essential to normal growth and development
 Each infant is unique

 Sucking and rooting
 Response is difficult if not impossible to elicit after infant has been fed; if response is weak or absent, consider preterm birth or neurologic defect
 Parental guidance: avoid trying to turn head toward breast or nipple; allow infant to root
 Response disappears after 3-4 months but can persist up to 1 year

 Swallowing
 If response is weak or absent, this can indicate preterm birth, effects of maternal analgesics, or illness that needs investigation
 Sucking, swallowing, and breathing are often uncoordinated in preterm infant

 Grasp
 Palmer: response lessens by 3-4 months; parents enjoy this contact with infant
 Plantar response lessens by 8 months
 Weak or absent reflexes can indicate CNS depression

 Extrusion
 Response disappears about fourth to fifth month.

 Glabellar (Myerson)
 Continued blinking with repeated taps is consistent with extrapyramidal signs.

 Tonic neck or “fencing”
 Responses in leg are more consistent
 Complete response disappears by 3-4 months; incomplete response may be seen until third or fourth year
 After 6 week persistent response is sign of possible cerebral palsy

 Moro
 Response is present at birth; complete response may be seen until 8 week; body jerk only is seen between 8 and 18 week; response is absent by 6 month if neurologic maturation is not delayed; response may be incomplete if infant is in deep sleep state; give parental guidance about normal response
 Asymmetric response can connote injury to brachial plexus, clavicle, or humerus
 Persistent response after 6 month indicates possible neurologic abnormality.

 Stepping or “walking”
 Response is normally present for 3-4 weeks

 Crawling
 Response should disappear about 6 week of age

 Crossed extension
 This reflex should be present during newborn period

 Babinski (plantar)
 Absence requires neurologic evaluation; should disappear after 1 year of age
 Response depends on infant’s general muscle tone, maturity, and condition

 Pull-to-sit
 Response depends on general muscle tone and maturity and condition of infant

 Truncal incurvation (Galant)
 Response disappears by fourth week
 Response varies but should be obtainable in all infants, including preterm ones
 Absence suggests general depression of nervous system
 With transverse lesions of cord, no response below level of lesion is present

REFLXES
 Magnet
 Absence suggests damage to central nervous system
 Weak reflex may be seen after breech presentation without extended legs or may indicate sciatic nerve stretch syndrome
 Breech presentation with extended legs may evoke exaggerated response

 Additional newborn responses:
yawn, stretch, burp, hiccup, sneeze
 Parental guidance: most of these behaviors
are pleasurable to parents
 Parents need to be assured that behaviors are normal
 Sneeze is usually response to mucus in nose
and not indicator of a cold
 No treatment is needed for hiccups;
sucking may help.
 In preterm infant these are signs of
neurodevelopmental immaturity
and physiologic stress

NEWBORNS DON’T ‘PLAY’
Newborn Bonding/ Attachment to their mother
They do have nonnutritive sucking / bonding with mother:

Sucking is a newborns chief pleasure. Nonnutritive sucking has also been shown to help improve weight gain in preterm infants, and decreased crying. Also, evidence that pacifiers reduce the likelihood of SIDS. Never coat pacifiers in any sweet solution. Wait to promote pacifier use in breastfeeding infants for at least 3-4 weeks to ensure that breastfeeding is well established.

Newborns can distinguish their mother’s voice from, also they respond to higher pitched voices as well.

They also learn to distinguish the odor of their mother’s breast milk. As a fetus, the newborn became accustomed to the mother’s heartbeat. A recorded heartbeat can be used to help sooth a crying newborn. Mothers and newborns actively participate in reciprocity. Reciprocity takes several weeks to develop ie: the newborn is fussy and the mother picks it up cradling and talking to the newborn and the newborn becomes quiet and establishes eye contact.

TEMPERAMENT |
Language/Speech: Newborns cry. Period. They cry for all of their needs- hunger, sleep, boredom, discomfort, and sometimes for no reason at all. Environmental tension can also add to the length and the intensity of the crying.

There are three major patterns of behavioral style that affect temperament of newborns:

The easy child: regularity in bodily functions, adapts to change easily, predominately positive mood, moderate sensory threshold, approaches situations with moderate responses

The slow-to-warm-up child: low activity level, withdraws on first exposure to new stimuli and slow to adapt in intensity of response, somewhat negative mood.

The difficult child: irregular in bodily functions, intense in reactions to new stimuli, generally negative mood and resistant to change and often cries loudly for long periods of time.

HABITUATION
Allows newborn to be accustomed to environmental stimuli. This is a psychologic and physiologic response to repetitive stimulus. Ie: shining a bright light into a newborns eyes causes a startle or squinting the first 2-3 times, later becomes accustomed to it and as the stimulus continues the response stops. The newborn learns to the sounds of the home environment and can learn to sleep.

Other factors that fall under temperament are consolability, cuddliness, irritability, and crying.

Newborns vary their cry based on their needs, gestational age and weight. A high pitched cry can be a sign of a neurologic disorder. Newborns may cry for as little as 5 minutes or 2+ hours a day. The amount of crying though peaks in the second month and then decreases. There is a diurinal rhythm of crying with more crying occurring in the evening hours.

NUTRITION
The neonatal period is when feeding practices
and patterns are established. Exclusive breastfeeding is recommended for the first 6 months of the baby’s life.

Benefits to mothers who breastfeed increase with the number of children breastfed and the duration of each child breastfeeding.
Some of the benefits for mothers & infants from breastfeeding: (all can be found on table 24-1)

Infants: Reduced risk for:
Celiac disease
SIDS
Otitis media
Obesity in adolescence
Clinical asthma, atopic dermatitis, and eczema

Mothers:
Decreased postpartum bleeding and more rapid uterine involution
Unique bonding experience
Increased maternal role attainment
Major factors that inhibit breastfeeding are
Lack of support by their partner/families
Employment and need to return to work
Lack of knowledge of benefits



Choosing to formula feed:
Most choose to formula feed because of lack of support for breastfeeding or lack of knowledge about benefits of breastfeeding. Also support and comfort play important roles for women to stick with breastfeeding and not revert to formula feeding.

Contraindications to breastfeeding:
Maternal diagnosis of HIV (but not in developing countries) is a contraindication, as well as, active TB infection, herpes simplex lesions on the breasts, human t-cell lymphotropic virus type I and II and untreated brucellosis and mothers receiving chemotherapy.

NUTRIENT NEEDS
Fluids:
During the first two days of life the fluid requirement for healthy infants (over 1500 grams) is 60-80 ml of water per kg per day. From day 3-7 100-150ml/kg/day. From day 8-30 its 120-180ml/kg/day
In general neither breastfed or formula babies need to be given water. (breastmilk contains 87% water) water decreases the caloric intake which newborns need during this time.
Energy
: For the first three months of life the infant needs 110kcal/kg/day. This provides energy for growth, digestion, physical activity and maintenance of organ metabolic function.
Carbohydrates:
for the first 6 months of life the recommended carbohydrate intake is 60g/day. Newborns have a poor hepatic glycogen store so 40-50% of the caloric intake should be carbs. The primary carbohydrate in human milk and put into formula is lactose. It’s slow breakdown and and absorption heps increase calcium absorption. The oligosaccharides found in breast milk are needed in the development of the microflora in the intestines. These promote an acidic environment to prevent gram-negative bacteria growth and later increase resistance to gi illness.
Fats:
major energy source, as much as 50% of the calories in breastmilk or formula, recommended consumption of fat for infants younger than six months is 31 grams per day.
Protein:
Requirement per unit of body weight is greater in the newborn than any other time of life. Younger than 6 months is recommented 9.1 grams/day.
Vitamins:
human milk provides all vitamins required for infant nutrition with the exception of vitamin D. all infants who are breastfed should reciev 400 international units of vitamin d daily in the first few days of life. The gut (intestinal bacteria) doesn’t produce vitamin K until a few days post birth. Intake of vitamin b12 is dependent on mother’s diet. Vegetarian or vegan mothers are at highest risk for vit b12 deficiency and need to supplement their infants (if breastfeeding)
Minerals
: unmodified cows milk has much higher mineral content than human milk (hence why its not suitable for infants during their first year. Minerals are highest in breast milk during the first few days after birth and decrease throughout lactation.
Calcium phosphorous levels of human milk is 2:1 this is ideal ratio for bone mineralization. Cows milk;s ratio is lower= decreased calcium absorption. Younger infants fed cows milk are at risk for hypocalcemia, seizures and tetany. Infant formula’s ratio is inbetween human and cow’s milk.
Iron is low in all milks but easier absorbed from human milk than cows, or other infant formula.

Maternal milk supply changes as nutritional and immunological needs of the infant changes.

Supporting breastfeeding mothers:
Always offer women a chance to breastfeed and express the (maternal and infant) benefits of breast feeding even when moms have expressed desire to formula feed. Help mothers recognize infant-readiness cues, or early signs of hunger- don’t wait for the baby to cry in distress
-hand-to-mouth movements
-sucking motions
-rooting reflex
-mouthing
Ideal time to initiate first breastfeeding is within the first hour after birth. Early skin-to-skin contact associates with higher rates of exclusive breastfeeding in hospital.
Four traditional holds for breastfeeding to teach the new moms:
Food ball or clutch hold
Modified cradle/across the lap cradle
Side lying
And cradle
Before the mother leaves the hospital the nurse should help the mother attempt all of these positions to ensure confidence and establish her preference.

Newborns breastfeed 8-12 times in a 24 hour period (or every 2-3 hours) During the first 24- 48 hours infants often don’t wake up this often to fed so parents should be sure to wake their baby this often to feed.

The duration of early feedings average 30-40 minutes, divided between the two breasts.

Signs of effective breastfeeding: box 24-2

Infant: latches without difficulty, has bursts of 15-20 suck/swallow at a time, appears content after feeding has at least 3 substantive bowel movements, 6-8 wet diapers every 24 hours after day 4

Mother: breasts soften or feel lighter while feeding, feels relaxed and drowsy while feeding, increased thirst
Infants should have at least 3 stools quarter size or larger per day for the first month.

-interesting fact- there is a relationship between maternal weight and infant feeding decisions: women who are overweight or obese are less likely to breastfeed than women who are underweight or average weight.
http://www.google.com/search?q=babinski+reflex&rlz=1C2TSND_enUS402US457&nord=1&biw=1455&bih=705&site=webhp&source=lnms&tbm=isch&sa=X&ei=f4z_VP2MKcOuggSFrYCICg&sqi=2&ved=0CAcQ_AUoAg#nord=1&tbm=isch&q=infant+reflexes+chart&revid=1322357524&imgdii=_&imgrc=Mxjgohy0QUiPRM%253A%3ByeWL9zJq6n-bBM%3Bhttp%253A%252F%252F217.196.164.19%252Fwww%252Ftables%252F1522.jpg%3Bhttp%253A%252F%252Fgalleryhip.com%252Finfant-reflexes.html%3B929%3B1300
Special Considerations:
Waking babies for feedings-
parents are most successful when babies are awakened from light or active sleep (when there is eyelid or body movements.
Feeding fussy babies:
swaddling the baby holding close and allowing them to suck on your finger. Refusing to eat and persistent crying can be attributed to gi upset or illness, just tell parents to notify their provider if either occur.
Slow weight gain:
newborns typically lose 5-6% of body weight after birth before they begin to gain weight. A weightloss of more than 7% in the first three days in a breastfeeding infant needs to be further assessed. Slow weight gain is attributed to inadequate breastfeeding.
Jaundice:
to prevent early-onset jaundice or breastfeeding-associated jaundice newborns wshould be breastfed frequently during the first several days of life.
Preterm Infants:
breastmilk ideal food- enhances retainal maturation and improves neurocognitive outcomes, and decreased risk of necrotizing enterocolitis.

Storing breastmilk:
Store in 2-4oz containers to prevent waste.
To thaw frozen breastmilk- place container in fridge for gradual thawing or under warm running water NEVER microwave or boil.

Thawed milk can be stored for 24 hours.
Shake milk and test temp before feeding to baby
Unused milk after feeding discard. Do not restore.

Guidelines:
Room temp- 3-4 hours optimal (6-8 hours acceptable)
Refrigerator 72hours optimal (5-8days acceptable)
Freezer 6 months optimal (12 months acceptable)

Care of mother:
Consuming a nutritious diet and adding an additional 450-500 calories to their diet should be sufficient. Even when adding calories to their diet, breastfeeding mothers tend to lose weight quicker than formula feeding.
Weightloss of 2.2-4.4 lbs per month is safe. Most women can consume a normal diet according to personal preference- continue to take prenatal vitamins as long as breastfeeding.
Drink to thirst- increasing fluids does not increase milk supply, and overhydration actually decreases milk production.
Rest especially during the first 1-2weeks after birth.

Breast care:
Avoid washing the nipples with soap because of a drying effect. Creams should be avoided as well because of chances of blocking the natural oils secreted by the glands.
Hormonal contraception are not recommended because of the potential for reducing milk supply. So, use NFP, or barrier methods.

Formula feeding:
Feeding patterns:
in first 24-48 hours of newborns consume 15 to 30 ml of formula at feeding. Gradually intake the first week of life. Newborns are drinking 90-150ml at feeding by the end of the second week or sooner.
Your provider will discuss different infant formulas to feed your baby with
Feeding Technique:
Hold the infant in a semi-upright position with good head suppport.
If the infant spits up, decrease feeding amounts and feed more frequently, avoid laying the baby on its stomach, or bouncing for at least 30 minutes and burping the baby when the baby starts to suck slower.
Boiling feeding equipment is the safest bet for babies, but be cautious to avoid plastic bottles that do not specify that they are BPA free.

• Palmar: finger in palm – baby’s finger
should curl around nurse’s fingers
• Plantar: finger at base of toes – toes should curl down
• Tonic neck: have baby supine, move neck quickly. Arm and leg on the side the neck turns to should extend out. The leg and arm on the other side should flex.
• Moro: baby should be supine on a flat surface and be exposed to a loud sudden noise. There should be abduction and extension of the arms and the fingers should fan out
• Stepping: while holding the baby up, allow one foot to
touch a flat surface, the baby will perform a walking motion
• Deep tendon: using just your finger, the baby
should show these reflexes
• Crossed extension: press down on the knee of one leg and tickle that foot, the other leg should flex up and out in response
• Babinski: stroke the foot from the heel to the
toes and then across the ball of the foot. Toes
should fan out and the big toe should dorsiflex

REFLEXES
http://www.google.com/search?q=babinski+reflex&rlz=1C2TSND_enUS402US457&nord=1&biw=1455&bih=705&site=webhp&source=lnms&tbm=isch&sa=X&ei=f4z_VP2MKcOuggSFrYCICg&sqi=2&ved=0CAcQ_AUoAg#imgdii=_&imgrc=LJt8euFKDWW9zM%253A%3Bjl1u-dTgp-GSpM%3Bhttp%253A%252F%252Fhellomrdoctor.com%252Fwp-content%252Fuploads%252F2013%252F09%252Fbabinski-reflex-6.jpg%3Bhttp%253A%252F%252Fhellomrdoctor.com%252Fbabinski-reflex%252F%3B451%3B463
REFERENCES
HR resting 120-160 bpm,
sleeping 80-100,
crying up to 180;
listen at 4th intercostal space for 1 full minute

RR 30-60, listen for 1 full minute

HR and RR first before other assessments

Axillary temp 96.8 to 99.0

BP 80-90/40-50
VITAL SIGNS
ERICKSON
Aby, J. (2015). Newborn Nursery Information . In Stanford School
of Medicine . Retrieved from http://newborns.stanford.edu/
PhotoGallery/Teeth1.html

Perry, S., Hockenberry, M., Lowdermilk, M., &Wilson, D. (2014).
Nursing Care of the Newborn and Family. In Maternal child
nursing care (Fifth ed., pp. 577-636). St. Louis (Missouri),
Missouri: Mosby.
Aby, J. (2015).
ANTICIPATORY CARE
BATHING
Newborns do not need to be bathed everyday, giving a newborn a bath every other day will be often enough to meet their personal hygiene needs. Newborns should not be bathed directly after feeding them because it can cause them to regurgitate their food. Gather all of the supplies needed for the bath before beginning in order to reduce heat loss from the newborn. When you begin to bathe the newborn start with the face, be sure to not use soap on the face, wash the eyes using different parts of a clean wash clothe. When washing the newborn’s ears and nose do not use cotton-tipped swabs because they can cause injury. Use mild soap while washing the newborn’s body, rinse and dry directly after washing the body in order decrease body heat loss. Wash the neck and body first, then the hands and feet and wash the genital area last.
SKIN CARE
Newborn’s skin is very sensitive and should be monitored closely for any irritation. If the newborn’s skin is excessively dry then a non-scented and alcohol free lotion can be used on their skin. While washing the newborn’s skin gentle patting and soaking should be used instead of vigorous scrubbing. Their skin is also easily sunburned and should be shaded while outside.
CORD CARE
The cord should be cleansed with water around the base where it meets the skin, it should be kept clean and dry at all times. The newborn’s diaper should never be placed over the cord in order to keep it from getting infected. The cord should fall out after 10 to 14 days of life.
NAIL CARE
The newborn’s nails should not be cut until they have grown out past the skin in order to prevent injuring the baby. If the newborn is scratching themselves, loosely fitted mitts can be placed on the babies hands in order to protect the infant’s skin. The best time to trim or file the nails is when the baby is sleeping and they should be cut straight across to prevent them from being sharp.
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